Provider Demographics
NPI:1396910337
Name:RETTERBUSH, DAVID W (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:RETTERBUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3638
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3638
Mailing Address - Country:US
Mailing Address - Phone:229-244-0034
Mailing Address - Fax:229-244-1871
Practice Address - Street 1:403 COWART AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2635
Practice Address - Country:US
Practice Address - Phone:229-244-0034
Practice Address - Fax:229-244-1871
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20145208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000193278AMedicaid
GA$$$$$$$$$BMedicare PIN
GAC78455Medicare UPIN